Next Generation Surgical Training

The psychology of high performance is not a new area, dedicated mostly to the improvement and consideration of elite athletes.  Surgeons require many of the same skills.  Think about a professional golfer who has just hit the ball into the rough on the 18th. She now needs to recover to make par and carry on into the playoff. How does she stay calm, concentrate, figure out and execute the shot that she needs? The pressure is enormous. Athletes do this on a daily basis. As surgeons we relate to this sort of pressure. Many of the same processes utilised in high level sporting competition apply to surgeons recovering from complications.  Whilst athletes might actively train in these areas, surgeons tend to glean skills through exposure to excellent mentors, colleagues, or experiences.

In 2019, Ear + Eye is breaking new ground in incorporating mental or mind training into the official surgical training program. We look forward to including this in GENEYE.

To permit training of anterior segment surgery, the Eyesi® Surgical platform (VRmagic, Mannheim, Germany) is equipped with a cataract eye interface, cataract instrument set, and foot pedals (figure 1). Surgeons see the intraocular surgical field through the operating microscope. The view is in stereo and offers realistic depth of field. Focus and zoom can be altered by using the microscope foot pedal. The instrument handpieces are inserted through incisions in the model eye. The cataract patient model head can be operated on from a temporal or superior position.  This platform provides surgeons with a high-fidelity simulation of the set-up, equipment, and skills required for live intra-ocular surgery.

Eyesi® Surgical has been incorporated into many training programs around the world.  In 2018, Ear + Eye was pleased to join a list of elite Ophthalmic Surgical Training Facilities to offer this advanced technology.  In particular, we were proud to incorporate this technology into a structured program that continued to use other well regarded wet and dry simulation models and a high standard of teaching to develop what we believe to be an inclusive, thorough means for preparation of ophthalmic trainees for live intraocular surgical training.

In 2010, an American group published a report confirming that experienced surgeons performed better at a particular task using the Eyesi simulation platform than inexperienced surgeons or than those with no experience at all.1    This “construct validity” had previously been shown for some of the other tasks available on the same simulator.2,3 These studies and others, as well as significant hardware and software improvements of the VR simulator over the last 8-10 years have led to a large body of research surrounding VR training for cataract surgery.

Certain factors, including pressures on training facilities, reduced training and teaching time, operating theatre cost and efficiency requirements, increased number and complexity of procedures, patient awareness/resistance to taking part in training, and an overall focus on reducing error and cost relating to medical care have led to increasing pressures on surgical training programs over the last few years.  Virtual reality simulation is one method by which we aim to address some of these impacts at Ear + Eye.  We believe this program allows our trainees to practice in a safe, ethical, repeatable, and low-pressure environment whilst increasing their skills to the level required for live surgical practice.

In 2009, Rogers et al reported that implementation of a structured surgical curriculum including VR simulation had resulted in a significant (P < 0.001, almost 50%) reduction of ophthalmic resident cataract surgery complication rates.4  Later, in 2011, another group reported similar findings, with residents training using this virtual reality platform to have shorter phaco times, lower percentage powers, fewer intraoperative complications, and a shorter learning curve. 5 

VR cataract surgical training is therefore an extremely well validated tool that has been shown to improve safety and outcomes of cataract surgery performed by trainee surgeons.

At Geneye, we believe in furthering the education of all surgeons, not just trainees. We look forward to extending the benefit of VR to consultants, and to using this technology to train for the unexpected, or rarely occurring complication. Upskilling in these areas is critical, and should be performed frequently. The utility of virtual reality training for ophthalmologists is extensive. We are just scratching the surface.

 
Figure 1. Eyesi® Surgical platform (VRmagic, Mannheim, Germany)

Figure 1. Eyesi® Surgical platform (VRmagic, Mannheim, Germany)

 

References

1.     Privett B, Greenlane E, Rogers G, Oetting T.  Construct Validity of a Surgical Simulator as a valid model for capsulorhexis training. J Cataract Refract Surg 2010; 36:1835–1838

2.     Rossi JV, Verma D, Fujii GY, Lakhanpal RR, Wu SL, Humayun MS, de Juan E Jr. Virtual vitreoretinal surgical simulator as a training tool. Retina 2004; 24:231–236.

3.     Mahr MA, Hodge DO. Construct validity of anterior segment anti-tremor and forceps surgical simulator training modules; attending versus resident surgeon performance. J Cataract Refract Surg.  2008; 34:980–985.

4.     Rogers G, Oetting T, Lee A, et al.  Impact of a structured surgical curriculum on ophthalmic resident cataract surgery complication rates J Cataract Refract Surg 2009; 35:1956–1960

5.     Belyea DA, Brown SE, Rajjoub LZ.  Influence of surgical simulator training on ophthalmology resident phacoemulsification performance.  J Cataract Refract Surg 2011; 37:1756–1761

 

A major skill to be acquired prior to independent cataract surgical practice is the management of posterior capsular rupture, with or without vitreous loss. The posterior capsule is the thin layer at the back of the natural lens capsule that separates the eye into two compartments.  The posterior compartment is filled with vitreous, and any vitreous that presents to the anterior chamber requires careful, planned removal via anterior vitrectomy. With planning, this skill can be taught, and trainees can acquire the knowledge and enough practical experience to proceed to supervised anterior vitrectomy, with the end goal being independent practice by the completion of RANZCO ophthalmology training.  

Complication training is not just for trainees.  This area has often been under-emphasised during training, leading to a lack of the required skills to achieve good results.  In addition, technology and machines change frequently.  Add these conditions to the fact that these complications are rare, and it is obvious that we should be up-skilling frequently.   

The complications associated with poorly managed vitreous presentation include poor post-operative visual outcome due to uveitis, raised intraocular pressure, cystoid macular oedema, retinal detachment, and endophthalmitis.1 Recent research from the UK, where trainees gain considerable experience in cataract surgery with high surgical volume similar to Australian trainees, suggests that the average rate of posterior capsular rupture amongst junior and senior trainees is 2.48% and 1.41%, respectively.2 However, less than 10% of trainees surveyed recently within a single postgraduate UK training centre felt confident to complete cataract surgery complicated by posterior capsular tear without senior support.3 Corresponding figures amongst Australian ophthalmic trainees are lacking, and we have consequently commenced collection of this data. 

As with any surgical skill, especially complication management, management of vitreous loss requires both the knowledge of what to do and why as well as the equipment and skills to carry out the procedure.  Training in this task has become a significant focus at Ear + Eye throughout 2018.  Introduction was made with one of the first year lessons covering the basic information and skills, and some of our trainees attended a specific course on this topic run as the Advanced Training Day at the Australasian Society of Cataract and Refractive Surgeons Annual Meeting in Noosa during October.  The next step is Geneye 2019, where we look forward to sharing this training with a wider community of ophthalmologists.

We have developed an “anterior vitrectomy challenge” for use during these training courses.  During this challenge, the surgeon has 7 minutes during which to respond appropriately to development of a complication.  They need to adjust machine fluidics and complete the required steps to manage a posterior capsular tear.  Results are then presented as a score out of 100 (figure). Who will get the highest score?

 
Figure Example of data generated during “anterior vitrectomy challenge training”. As more repetitions are completed, graphical representation becomes useful in showing improvement or otherwise.

Figure Example of data generated during “anterior vitrectomy challenge training”. As more repetitions are completed, graphical representation becomes useful in showing improvement or otherwise.

References

1.     Ti Se, Yang YN, Lang SS, and Chee SP. A 5-Year Audit of Cataract Surgery Outcomes After Posterior Capsule Rupture and Risk Factors Affecting Visual Acuity. AJO 2014;157:180-5.

2.     Johnston RL, Taylor H, Smith R, Sparrow JM. The Cataract National Dataset electronic multi-centre audit of 55,567 operations: variation in posterior capsule rates between surgeons. Eye 2010; 24(5): 888–893.

3.     Turnbull AMJ and Lash SC.  Confidence of ophthalmology specialist trainees in the management of posterior capsule rupture and vitreous loss.  Eye. 2016;30:943-48

 

Microsurgery for junior doctors

Ophthalmology training, like all medical specialities, takes a long time of committed vocational training. How do you know if you will like it?

It’s not important to be good at microsurgery from the start - these skills are acquired and learned over time, but a natural degree of interest is essential. You need to care A LOT about details. You need to be willing to practice over and over until you get things right and you need to be practicing in the right way with good technique, right from the beginning. Eventually, somebody’s eyesight will be depending on that attention to detail. Near enough is not good enough when we are talking about 4 micron margins of error and suturing with 10-0 nylon!

It will be a privilege for some of our senior instructors to take medical students and junior doctors through the basics of eye surgery, and to introduce them to hands on practice. Videos of cataract surgery are amazing, but 3D surgeons view footage is so much better. Just wait until you get to see what we see when we are looking down the operating microscope! We also look forward to showing you how to operate a surgical microscope, how to suture with very fine material, the types of instruments that we use and how to handle them. Best of all, we look forward to showing you that ophthalmologists get to utilise a lot of technology. Come and experience eye surgery live in virtual reality. This could be your future. We need minds like yours to come and learn these skills, and to develop this profession beyond where we are at today.

Surgery is the best part of our job, and technology is the best part of surgery. We can’t wait to share it with you.

Come and experience this. Ophthalmology might be for you.